Aortic valve replacement with frame-supported autologous fascia lata grafts. III. Haemodynamic and angiographic findings.

Thirty-two patients with a frame-supported, autologous, fascia lata graft implanted in the aortic annulus were investigated 11 to 36 months after the operation. The group comprised 7 patients with pure aortic stenosis, 10 with combined aortic stenosis and aortic incompetence and 15 with pure aortic incompetence. Six patients had concomitant mitral valve disease. The follow-up investigation included right heart and transseptal left heart catheterization, left ventricular angiocardiography through the transseptal route and a retrograde, supravalvular aortography with the cinétechnique. Cardiac output was essentially unchanged postoperatively. However, it had increased considerably in some patients in whom it was very low before the operation. Left ventricular systolic pressure decreased particularly in patients with pure aortic stenosis. Left ventricular enddiastolic pressure decreased from 12 to 7 mmHg at rest and from 25 to 18 mmHg during exercise. Left atrial (or pulmonary arterial wedge) mean pressure decreased from 14 to 2 mmHg at rest, and from 27 to 16 mmHg during exercise. In 76% of the patients a slight (grade I or II) central or paravalvular aortic regurgitation was observed on cinéangiograms. Regurgitation of grade III was found in one patient. Technical details in the construction of the valve, as well as structural changes in the fascia lata which may be responsible for stenosis and incompetence in some of these valves are discussed. Thus, although even patients with defective valves have shown considerable improvement, a close and continuous follow-up of these patients is necessary.     

Aortic valve replacement with frame-supported autologous fascia lata grafts. I. Technical consideration and early results.

During the period November 1969 to June 1972, a frame-supported autologous fascia lata graft was implanted in 71 consecutive patients with surgically treated aortic valve disease at the Department of Thoracic & Cardiovascular Surgery, University Hospital, Uppsala. The follow-up period was between 1 and 4 years. Eleven patients died within 28 days of the operation (16%) and 13 after discharge from hospital (18%); the cumulative mortality was thus 34%. Forty-five percent of the patients who died had associated cardiovascular or other diseases. The causes of death were infection (10), myocardial failure (6), myocardial infarction (3), cerebral damage (3), and intraoperative aortic dissection from the cannulation site (2). The majority of the deaths (88%) occurred within 6 months and all within 13 1/2 months after operation. Two fascia lata valves were removed because of endocarditis 23 and 26 months, respectively, after operation. Two valves were also removed on account of mechanical malfunction. The remaining 44 patients with fascia lata valves had returned to work. No embolic complications occurred, despite the fact that only patients with a concomitant prosthetic mitral valve or atrial fibrillation received anticoagulatant treatment. Haemodynamic studies of the valve in vitro and pressure measurements during the operation showed that the valve had a low primary systolic peak gradient of 0-16 mmHg. Certain modifications in the construction aimed at improving the haemodynamic properties of the valve are discussed. Increased stringency in the sterility precautions during the valve construction procedure may have contributed to the fact that early endocarditis, which is a serious complication, did not occur in any of the last 43 patients. As yet the observation time is too short to judge, however, to what extent susceptibility to infection and possible late changes of the valve can affect its function.     

Aortic valve replacement with unsupported fascia lata

Hearn, K., Somerville, Jane, Sutton, R., Wright, J., and Ross, D. (1973).Thorax, 28, 603-607. Aortic valve replacement with unsupported fascia lata. Twenty-five patients in the National Heart Hospital have had aortic valve replacement with unsupported autologous fascia lata and have been followed for two to three and a half years. Three patients died before leaving hospital. Nine of the 22 survivors required re-operation for severe aortic regurgitation and the other 13 developed aortic incompetence. In 11, regurgitation dated from the operation and progressed; and in 11 it appeared later and progressed. In view of the disappointing results which were obvious within six months unsupported autologous fascia lata valves have not been used for aortic valve replacement since December 1970.     

Autologous fascia lata transplantation for heart valve replacement: A two-year experience at the National Heart Hospital, London

Between April 1969 and December 1970, 201 patients underwent 262 valve replacements with frame-mounted autologous fascia lata valves in the aortic, mitral, and/or tricuspid positions at the National Heart Hospital. A single fascia lata valve was inserted in 146 patients and multi-valve replacement was performed in 55 instances. Hospital and late mortality are comparable with that following other procedures of heart valve replacement. One hundred and fifty-four patients with 193 fascia lata valves were available for follow-up. A retrospective analysis of this method of valve replacement has been undertaken to assess the suitability of fascia lata as a heart valve substitute as well as the clinical results achieved by this method of valve replacement.     

Autologous fascia lata for heart valve replacement

To obviate the drawbacks of prosthetic devices and in search of a better substitute for diseased heart valves a technique of using autologous fascia lata grafts attached to a support frame was developed. The technique of preparing mounted fascia lata grafts is briefly outlined and their surgical implantation into the mitral, tricuspid, and aortic areas is described. Since April 1969, 83 fascial grafts have been inserted into 76 patients with very good immediate and short-term results. Ten patients succumbed within the operative period. None of these deaths was due to failure of the graft per se. Thromboembolic manifestations have been completely absent although anticoagulants were not used. All sixty-six survivors are very much improved. Data concerning the structure and function of fascia are presented and the experimental and clinical use of fascia lata in extracardiac and cardiac surgery is reviewed. The use of autologous, living, fascia lata valves is considered to be a better approach for heart valve replacement because autologous fascia maintains its structure unchanged after transplantation and, being under mechanical stimulation, it retains its functional properties.     

Fascia lata aortic valve reconstruction: long-term results in 33 patients

Aortic valve reconstruction with autologous fascia lata was performed in 33 patients (mean age 35 years) in 1966 and 1967. Eighty-two per cent had cusp extension rather than replacement, while 33% required additional intracardiac procedures. There were seven hospital deaths (21%) and 11 late deaths (33%), a total mortality of 54% over four years. Six late deaths followed reoperation for recurrent incompetence, and two other patients survived reoperation. Endocarditis (rickettsial, fungal, and bacterial) occurred in five cases, all required reoperation for incompetence, and four died. Sixty-nine per cent of the survivors of operation left hospital with competent valves and did better than the 31% with leaking valves in terms of late deaths, endocarditis, and reoperation for incompetence. Of the 15 patients (45%) still alive, 13 still have their original fascial valve, and of these only two (or perhaps three) have no diastolic murmur. Seven have insignificant murmurs and three have aortic incompetence. These poor results, particularly in the long term, make us sceptical about current enthusiasm for fascia lata heart valves.     

Opening characteristics of three-cusp tissue heart valves

Since April 1969, frame-mounted three-cusp fascia lata and pericardial valves have been used in over 200 patients for heart valve replacement. Six autologous fascia lata valves have been removed from the mitral position because of regurgitation produced by shrinkage of one or two cusps. To elucidate the cause and mechanism of graft failure the opening characteristics of fascia lata and Silastic valves were studied in a steady state flow rig.     

A fascial frustum valve for aortic valve replacement

The promising qualities of autologous fascia lata in heart valve replacement have resulted in a search for improved methods of fascial heart valve manufacture. This paper describes a simply made and inserted and reliably competent unsupported fascial valve for aortic valve replacement.     

Banked Fascia Lata in Sellar Dura Reconstruction after Endoscopic Transsphenoidal Skull Base Surgery

Objectives Cerebrospinal fluid (CSF) leakage is an undesirable complication of transsphenoidal skull base surgery. The issue of the most appropriate sellar dura repair remains unresolved, although a multilayer technique using autologous fascia lata is widely used. We describe the novel application of a homologous banked fascia lata graft as an alternative to an autologous one in the reconstruction of sellar dura defects in endoscopic transsphenoidal surgery. Design The clinical records of patients who underwent endoscopic transsphenoidal surgery at our department from June 2012, when we started using homologous fascia lata, up to July 2014 were reviewed retrospectively. The data concerning diagnosis, reconstruction technique, and surgical outcome were analyzed. Results We treated 16 patients successfully with banked fascia lata. Twelve patients presented intraoperative CSF leakage, and four patients were treated for postoperative rhinoliquorrhea. Banked fascia lata was used in a single-to-multilayer technique, depending on the anatomical features of the defect and of the sellar floor. No complications or failures in sella reconstruction occurred. Conclusion A banked fascia lata graft proved reliable and safe in providing an effective sellar dura reconstruction. Used in a multilayer strategy, it should be considered a viable alternative to an autologous fascia lata graft.     

Cusp degeneration in frame-supported autologous fascia lata mitral valves: Clinical results in 67 patients

Sixty-seven metal-frame-supported autologous fascia lata mitral valves were placed in 67 patients. There was an operative mortality of 25% and an overall mortality of 40% within 20 months. Most of the late deaths were due to valve malfunction which occurred in 50% of survivors. Female patients demonstrated a much higher rate of valve dysfunction than did men. This mal-function of the fascial valves in the mitral position, which has not been observed in the aortic position, may be due to inappropriate design for the mitral position. The fascia is not exposed to the continued and reproducible mechanical stimulation in the atrioventricular position that it has when used as an aortic valve substitute. The mechanical properties of fascia may make it suitable for human valve substitutes but it is clear that an inverted three-cusped semilunar fascial valve will not be adequate for mitral or tricuspid valve replacements because of the haemodynamic characteristics of the atrioventricular position.     

A two-year experience with supported autologous fascia lata for heart valve replacement

Over a two-year period 262 supported living fascia lata valves were implanted in 201 patients. Early results were satisfactory from the point of view of valve function. After several months it became obvious that autologous fascia lata valves behave very differently in each of the three positions. A critical analysis is presented of 193 valves that were available for follow-up. After two years' experience with this method of valve replacement, it is the opinion of the authors that supported, living fascia lata valves are unsuitable for tricuspid valve replacement. In the mitral position they have shown an increasing incidence of systolic murmurs and evidence of regurgitation. The supported fascia valves have given the best functional results in the aortic position; however, not enough time has elapsed to assess their long-term function.     

Pulmonary vein flow pattern in mitral incompetence, combined mitral stenosis/incompetence and after prosthetic valve replacement.

Pulmonary vein flow (PVF) pattern was studied with an electromagnetic flowmeter in 11 patients with combined mitral stenosis/incompetence (MS/MI), in 6 patients with pure mitral incompetence (MI) and in 24 patients after mitral valve replacement (MVR). ECG, left atrial and left ventricular pressures were recorded simultaneously. The anomalous flow patterns, which were recorded, reflected the left atrial events and mitral valve function. Before MVR, the major forward flow occurred in ventricular diastole. In patients with predominating MS and small/moderate MI, a small retrograde PVF (RF) occurred in early ventricular systole, while pure or combined severe MI produced a holosystolic reversal of PVF.     

Reduction in left ventricular volume following aortic valve replacement does not predict improved ventricular function

Background  Aortic valve replacement in rheumatic disease is one of the procedures that clearly prolonged the life expectancy of adult patients. Our study objectives are to assess the mortality and morbidity associated with aortic valve replacement, and study the effects of successful, valve replacement on ventricular volume and performance in aortic stenosis and in aortic incompetence. Methods  Between January 1997 and December 2001, 148 patients underwent aortic valve replacement at our institution. The records of these patients were evaluated retrospectively. A total of 136 survivors were followed up both actively and passively. Results  There were 9 deaths (6.07%) with an early mortality at 30 days of 4.05% and valve related mortality of 4.05%. Bleeding events and operated valve endocarditis occurred infrequently (0.03% and 0.04% / patient year). 2 patients had nonstructural valve dysfunction (paravalvular leak) (0.02% / patient year). Following successful valve replacement, ventricular volume decreased substantially, while there was no significant increase in ventricular performance in aortic stenosis, and aortic incompetence. Conclusion  Aortic valve replacement can be performed today with a low mortality and morbidity. Although the ventricular volume and cardiac size reduced substantially following valve replacement, the ventricular performance remained unchanged in aortic stenosis, and aortic incompetence because of the impaired ventricular function pre-operatively and because the ejection fraction tends to over estimate contractile function in aortic regurgitation. Low preoperative ejection fraction is therefore an important risk factor for postoperative left ventricular dysfunction.     

下肢深静脉功能不全诊治的实验与临床研究

目的 寻找下肢深静脉瓣膜包窄术最佳环包材料,了解彩超对深静脉瓣膜功能不全的诊断价值和Ｇｕｏ静脉膜功能。方法 （１）观察３０条实验犬以自体大隐静脉片、自体阔筋膜和人造血管片作深静脉膜包窄术的效果;（２）对７８例彩超与经Ｇｕｏ静脉插管造影结果对比;（３）观察正常人与患者Ｇｕｏ静脉瓣膜血液动力学变化。结果 自体阔筋膜和大隐静脉逐渐挛缩呈纤维化瘢痕增生,而膨胀聚四氟乙烯人造血管的形态和结构无明显变化;彩超     

Rehabilitation after Aortic Valve Replacement with Autologous Fascia Lata: A Sodomedical Study

In a series of 50 patients who underwent aortic valve replacement with frame-supported fascia lata, 32 were seen for a combined medical and psychosocial examination 10 to 33 months postoperatively. The investigation included a psychometric test battery and an interview concerning the patient's social and psychological situation at the time of the operation and at follow-up.Twenty-seven patients had improved in their New York Heart Association Functional Classification at the time of follow-up. In most instances NYHA classification correlated well with the patients' subjective opinion on their recovery. Those who for various reasons were not able to return to work did not consider themselves recovered. The employment rate after operation was 66%.There is a great need for more information and support to families as well as for more intensive rehabilitation efforts, especially vocational, for the postoperative patient.     

Replacement of heart valves with frame-mounted tissue grafts

Ionescu, M. I., Pakrashi, B. C., Mary, D. A. S., Bartek, I. T., and Wooler, G. H. (1974). Thorax, 29, 56-67. Replacement of heart valves with frame-mounted tissue grafts. Between April 1969 and March 1973, 213 patients had heart valve replacement with frame-mounted autologous or homologous fascia lata or with heterologous pericardial grafts. There were 111 single aortic, 95 single mitral, and seven tricuspid valve replacements.     

Postoperative changes in autologous fascia lata heart valve grafts. A pathological study

In a series of 45 consecutive patients undergoing insertion of frame-mounted autologous fascia lata heart valve grafts, 11 of the grafts were examined microscopically following different durations of implantation, 8 of them at postmortem examination, in order to study the reaction of the implanted fascia tissue. Three of these grafts were also examined by radioautography.Signs of infection were observed in 5 of the 11 grafts studied microscopically. One important reason for infection in these patients must be that the fascia is exposed to a considerable risk of contamination during dissection and preparation. Strict sterility precautions must therefore be observed during tailoring of the grafts. On the other hand, it was found that fascia lata cells were able to remain viable and retain their metabolic activity for at least eighteen months after implantation of the tissue.     

Fascia lata valves: a clinicopathological study.

Sixteen frame-mounted fascia lata valves removed from the mitral, aortic or--in one patient--pulmonary position have been detailed histologically. These valves had remained in 15 patients (11 men and four women) for periods varying between 10 and 44 months. The reason for the original transplantation was either chronic rheumatic endocarditis or calcific aortic disease. In the mitral position, the leaflet in position nearest the site of the original anterior mitral valve cusp showed the least changes. The remaining two leaflets of the fascia lata valve in the mitral position, as well as those removed from the aortic or pulmonary position, showed more severe changes; these consisted of degeneration of collagen tissue and often a severe decrease of nuclei belonging to the fibroblastic series. These changes, as well as superimposition of fibrin or fibrous tissue, tended to become more pronounced the longer the valve had remained in the patient. Viability studies in valves removed from two patients have also been undertaken showing very greatly reduced activity. The possible causes for valve dysfunction have been reviewed, and the findings in this study suggest that contraction of fibrous tissue, which sandwiches the fascia lata valve cusps, may contribute to failure of satisfactory valve function. It is concluded that fascia lata forms a poor substitute for replacement of diseased cardiac valves.     

Fascia lata composite graft for right ventricular outflow tract and pulmonary artery reconstruction: Surgical technique

Because there is no `ideal' method for the complete correction of some of the more complex congenital cardiac abnormalities, a technique of making a composite graft of autologous fascia lata has been developed.

Three types of grafts are described, all of them being based on the same general principle. The composite graft comprises a conduit, which serves to enlarge or reconstruct the outflow tract of the right ventricle and the main pulmonary artery, and an inner valve attached inside it, which provides the conduit with a one-way flow mechanism.

The technique of preparing these composite grafts is outlined and the surgical implantation of the grafts in the right ventricular outflow is described.

Since November 1969, fascia lata composite grafts have been used in 18 patients with a variety of complex congenital heart malformations with very good early results.

     

222. Gegenwärtiger Stand der autologen Fascia lata-Transplantation beim Herzklappenersatz

Zusammenfassung Die Resultate nach Implantation von 327 külichen Herzklappen aus autologer Fascia lata bei 262 Patienten am National Heart Hospital London (April 1969–Dezember 1970) enthüllen bei vergleichbaren Frühergeb-nissen ein differentes Verhalten gleichartiger Prothesen in unterschiedlichen Klappenpositionen: Früitige Degeneration der Klappensegel macht Fascie für den Klappenersatz im rechten Herzen unbrauchbar. Im linken Herzen sind die Spätergebnisse nach Aortenklappenersatz wesentlich günstiger als nach Mitralklappenersatz. Mitralklappen sind nach Häufigkeit und Schweregrad stärker von Insuffizienzsymptomen betroffen als Aortenprothesen. Die Ursachen für diese unterschiedliche Verhaltensweise könnten mechanischer Natur sein (Klappen modell, unterschiedliche Hämodynamik, Klappenöffnungsdruck) oder in den Gewebeeigenschaften lebender Fascie (Elastizitätsarmut, Orientierung der kollagenen Fasern bei unterschiedlichem Stress) begründet liegen. Diesen Problemen könnte z. T. in der Verwendung freier Fascientransplantate mit natürlichem Klappenbauplan begegnet werden (wie am NHH bei 62 Klappen erfolgt). Gewebsreaktionen sind evtl. durch die Benutzung nichtlebender Fascie vermeidbar.

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The present state of autologous fascia lata transplants for the replacement of cardiac valves

Summary The results obtained with implantation of 327 artificial cardiac valves fashioned from autologous fascia lata in 262 patients treated at the National Heart Hospital, London, between April 1969 and December 1970 show that although the early results are comparable, similar protheses can behave differently according to the position of the valves. Early degeneration of the cusps of the valves rules out the use of fascia for the substitution of valves in the right heart. In the left heart, later results obtained with aortic valve replacement are substantially better than in the case of mitral valve substitution. Mitral valves, both with regard to incidence and degree of severity, are more likely to develop signs of insufficiency than aortic protheses. The causes for this different behaviour are probably of a mechanical nature (valve-model, variable haemodynamics, valve-opening pressure) or are to be found in the tissue characteristics of living fascia (poor elasticity, orientation of collagen fibres under variable stresses).These problems could probably be overcome to a certain extent by the use of free fascia transplants in the shape of normal valves (this was done at the N.H.H. with 62 valves).Tissue reactions can possibly be avoided by using nonliving fascia.